On the eve of World AIDS Day, the World Health Organization (WHO) is releasing new recommendations on treatment, prevention and infant feeding in the context of HIV, based on the latest scientific evidence.

WHO now recommends earlier initiation of antiretroviral therapy (ART) for adults and adolescents, the delivery of more patient–friendly antiretroviral drugs (ARVs), and prolonged use of ARVs to reduce the risk of mother–to–child transmission of HIV. For the first time, WHO recommends that HIV–positive mothers or their infants take ARVs while breastfeeding to prevent HIV transmission.

“These new recommendations are based on the most up to date, available data,” said Dr Hiroki Nakatani, Assistant Director General for HIV/AIDS, TB, Malaria and Neglected Tropical Diseases at the World Health Organization. “Their widespread adoption will enable many more people in high–burden areas to live longer and healthier lives.”

An estimated 33.4 million people are living with HIV/AIDS, and there are some 2.7 million new infections each year. Globally, HIV/AIDS is the leading cause of mortality among women of reproductive age.

New treatment recommendations
In 2006, WHO recommended that all patients start ART when their CD4 count (a measure of immune system strength) falls to 200 cells/mm3 or lower, at which point they typically show symptoms of HIV disease. Since then, studies and trials have clearly demonstrated that starting ART earlier reduces rates of death and disease. WHO is now recommending that ART be initiated at a higher CD4 threshold of 350 cells/mm3 for all HIV–positive patients, including pregnant women, regardless of symptoms.

WHO also recommends that countries phase out the use of Stavudine, or d4T, because of its long–term, irreversible side–effects. Stavudine is still widely used in first–line therapy in developing countries due to its low cost and widespread availability. Zidovudine (AZT) or Tenofovir (TDF) are recommended as less toxic and equally effective alternatives.

The 2009 recommendations outline an expanded role for laboratory monitoring to improve the quality of HIV treatment and care. They recommend greater access to CD4 testing and the use of viral load monitoring when necessary. However, access to ART must not be denied if these monitoring tests are not available.

Preventing mother–to–child transmission and improving child survival
In 2006, WHO recommended that ARVs be provided to HIV–positive pregnant women in the third trimester (beginning at 28 weeks) to prevent mother–to–child transmission of HIV. At the time, there was insufficient evidence on the protective effect of ARVs during breastfeeding. Since then, several clinical trials have shown the efficacy of ARVs in preventing transmission to the infant while breastfeeding. The 2009 recommendations promote the use of ARVs earlier in pregnancy, starting at 14 weeks and continuing through the end of the breastfeeding period.

WHO now recommends that breastfeeding continue until the infant is 12 months of age, provided the HIV–positive mother or baby is taking ARVs during that period. This will reduce the risk of HIV transmission and improve the infant’s chance of survival.

“In the new recommendations, we are sending a clear message that breastfeeding is a good option for every baby, even those with HIV–positive mothers, when they have access to ARVs,” said Daisy Mafubelu, WHO’s Assistant Director General for Family and Community Health.

National health authorities are encouraged by WHO to identify the most appropriate infant feeding practice (either breastfeeding with ARVs or the use of infant formula) for their communities. The selected practice should then be promoted as the single standard of care.

Benefits and challenges
An earlier start to antiretroviral treatment boosts the immune system and reduces the risks of HIV–related death and disease. It also lowers the risk of HIV and TB transmission.

The new prevention of mother to child transmission (PMTCT)

recommendations have the potential to reduce mother–to–child HIV transmission risk to 5% or lower. Combined with improved infant feeding practices, the recommendations can help to improve child survival.

The main challenge lies in increasing the availability of treatment in resource–limited countries. The expansion of ART and PMTCT services is currently hindered by weak infrastructure, limited human and financial resources, and poor integration of HIV–specific interventions within broader maternal and child health services.

The recommendations, if adopted, will result in a greater number of people needing treatment. The associated costs of earlier treatment may be offset by decreased hospital costs, increased productivity due to fewer sick days, fewer children orphaned by AIDS and a drop in HIV infections.

Another challenge lies in encouraging more people to receive voluntary HIV testing and counselling before they have symptoms. Currently, many HIV–positive people are waiting too long to seek treatment, usually when their CD4 count falls below 200 cells/mm3. However, the benefits of earlier treatment may also encourage more people to undergo HIV testing and counselling and learn their HIV status.

WHO, in collaboration with key partners, will provide technical support to countries to adapt, adopt and implement the revised guidelines. Implemented at a wide scale, WHO’s new recommendations will improve the health of people living with HIV, reduce the number of new HIV infections and save lives.

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